Full Capacity

Gross Anatomy and 2md are on a roll lately -- which seems like the appropriate response to the mounting stress of second-year spring. Why else do class shows occur right before the Step I exam? It's creativity in the face of selective pressure; flowers do something similar this time of year.

Both sites have recently tackled the role of medicine in allowing self-destructive behavior.

2md asks, if anorexic patients can be hospitalized against their will, why not the morbidly obese?

Grahamazon wonders if double-stuffed oreos shouldn't include a picture of atherosclerosis on every box (among other things).

I remember this kind of idealism (or paternalism, more accurately) from my pre-clinical years, when the unhealthiness of the Western lifestyle was drummed home. There's a lot of backpedaling from this beginning with third-year, when armchair philosophy is forced to compete with tight schedules, long lists, and the already-atherosclerosed. Not to mention the elaborate denials, defenses, and patient enablers that flatly reject your appeal to reason.

Even so, there are times when patients lose their rights. My recollection from my psych rotation: patients can be said to have lost their medical decision-making capacity if they cannot meet Appelbaum's four criteria:

1. Communicate and maintain a choice
2. Demonstrate a factual understanding of the situation (diagnosis, prognosis, risks and benefits of therapy)
3. Appreciate the siutation and its consequences (you could die without intervention, etc)
4. Manipulate data rationally to arrive at this decision

I'm leery to post anything on anorexia, since they're a resourceful cohort that have used the web to sustain their pathology before. But I think it's safe to say they get tripped up on #3; anorexics simply don't think they're close to death, and they could still stand to lose a few pounds.

In my state, when a patient is found to lack medical decision-making capacity, a hospital representative takes it to a judge. If the courts find a patient to lack competency, a guardian is then appointed and given limited powers regarding the decision at hand. In the case of an anorexic patient, the guardian would approve resuscitation and psychiatric interventions.

The situation with capacity in the morbidly obese seems more ambiguous, mostly because their prognosis is less emergent, and the interventions more diverse. Unlike anorexia, I don't think many obese people are opposed to their doctor's recommendations. If anything, I suspect they get tripped up on criteria #1 -- they cannot maintain the choice to eat less. Do you appoint a guardian to follow them around, watching their diet and making them take the stairs?

The increasingly indicated therapy for a BMI over 40 is bariatric surgery, but I'm not aware if there are legions of obese patients refusing this option. Given the explosion of this field in recent years, it seems that many are amenable to it, when it's offered. No guardianship seems necessary in these cases.

Cooney once wrote that a competent person chooses to run risks, an incompetent person simply runs them. At first but it seems glib to me: plenty of competent people forget to put on their seatbelts, or ask for that extra helping of dessert. But Cooney's phrasing is growing on me. If there's a matter that's important to you, but you continually fail to treat it that way, well, yes, you lack capacity in that area. If your family and doctor are on top of things, they should call you on it, and see that you get help. This is how it should work for alcoholism, for eating disorders, and for other destructive behaviors.

What my fellow bloggers may be getting at, though, is intervening before overeating leads to morbid obesity. This, actually, is too paternalistic. Not all obesity is pathological, and the jury's still out on whether the health risks come from obesity or the sedentary lifestyle that accompanies it.

The issue in intervening in these destructive behaviors isn't the medical community's lack of vigilance or authority. Rather, it's a failing of human nature: many diseases move glacially, and inertia is a hard thing to overcome. There are plenty of people who come into the doctor's when a tiny mole changes, but there are others who can convince themselves that nothing's wrong even as half their face is eaten away by cancer.

How do you fight this facet of human nature? I don't know -- but I'm more disposed to raising awareness and fighting inertia in the people who need it, rather that taking away their rights.

As a postscript, I'd like to mention some published discussions of the consequences of Appelbaum's capacity criteria. For instance, one could argue that any patient who disagrees with a physician's recommendations hasn't, in fact, "appreciated the circumstances" of his or her illness (criteria #3). i.e., if they really did understand and appreciate the relevant facts, they'd go along with the proposed treatment, right? Contrastic views on this and other topics have been nicely addressed by Wenger and Stone.